Back Pain History

  • CC:
    • Site: where? Uni\bi-lateral? Other joints? Radiates anywhere else?
    • Onset: first time? When? Sudden\gradual? Continuous\intermittent? What were you doing?
    • Timing: day\night? How frequent?
    • Character: dull, sharp, burning, electric-like?
    • Aggravating\relieving factors: coughing, bending, exercise, medications, laying down, massage, heat\ice packs?
    • Severity: 1-10 scale? Wakes you up from sleep? Interfering w\ ADL?
  • Associated sx:
    • Constitutional: fever, wt loss, loss of appetite, night sweats, chills?
    • Neurological: weakness, numbness, gait imbalance?
    • Cauda equina: urinary\bowel incontinence?
    • Ankylosing spondylitis: morning stiffness, joint pain, blurred vision?
    • UTI: dysuria, urgency, hematuria?
    • Psych: depression, stress?
  • PMHx:
    • Diseases:
      • Chronic ds (HTN, DM, DLP)
      • Renal ds
      • Osteoporosis
      • Infections (TB)
      • Malignancy
    • Medications: OTC, steroids, HRT
    • Surgery, hospitalization, trauma
    • Blood transfusions, IV drug use, tattoos
    • Allergies
  • FMHx:
    • Similar complaint?
    • Same diseases as in PMHx?
  • Social Hx:
    • Occupation, living situation, marital status, children?
    • Smoking, alcohol, recreational drugs?
    • Travel Hx, contact w\ sick pts?
    • Diet, exercise

 


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